Informatics and Financial Incentives Can Lead To Safer Drug Prescribing Interview with:

Prof. Bruce Guthrie Primary Care Medicine and Honorary Consultant NHS Fife University of Dundee Dundee, Scotland

Prof. Bruce Guthrie

Prof. Bruce Guthrie
Primary Care Medicine and Honorary Consultant NHS Fife
University of Dundee
Dundee, Scotland What is the background for this study? What are the main findings?

Dr. Guthrie: Most drug-related harm is caused by commonly prescribed drugs with moderate risk. This prescribing is not always inappropriate, because risk of harm may be outweighed by benefit in an individual, but we have previously shown that high-risk prescribing like this is common and highly variable between primary care practices, consistent with it being improvable. We therefore developed a complex intervention combining education, informatics to make it easy to identify and review patients, and a small financial incentive to review. We evaluated this intervention in a cluster-randomised trial in 33 Scottish primary care practices, targeting nine measures of high-risk non-steroidal anti-inflammatory drug (NSAID) and antiplatelet prescribing (for example, prescription of an NSAID to someone with chronic kidney disease; prescription of an antiplatelet to someone taking an anticoagulant without also prescribing a gastroprotective drug).

The intervention reduced the targeted prescribing by just over one third, and this reduction was sustained in the year after the intervention (including the payment to review) ceased. We also observed reductions in related hospital admissions with gastrointestinal bleeding and heart failure, although not acute kidney injury which was reduced but not statistically significantly. What should clinicians and patients take away from your report?

Dr. Guthrie: Prescribing is a high-benefit but also high-risk activity, and regular prescribing therefore needs reasonably regular review. There are several lists of ‘potentially inappropriate prescribing’ or ‘high-risk prescribing’. US clinicians will likely be most familiar with the Beers list (, but others may be useful such as these two ( and the more clinically focused Clinicians should consider which indicators are relevant to their context, and actively seek out such prescribing to review.

In the UK, high-risk NSAID and antiplatelet prescribing is common and causes considerable harm, and we would be surprised if this wasn’t the case in other countries. The physicians in our studies were often surprised by some of the prescribing they reviewed. Although the original decision to start prescribing had often been reasonable, continuation longer-term often just happened without an explicit decision, but then became inappropriate when an individual’s context changed (an original high-benefit indication ceased to apply; or the patient became frailer, developed a new condition, or was prescribed other drugs). What recommendations do you have for future research as a result of this study?

Dr. Guthrie: More research is needed to confirm the observed reductions in emergency hospital admission (a secondary outcome in our study) and to see if the intervention also works for other kinds of high-risk prescribing. For example, we would hypothesize that more facilitation might be needed for more ‘difficult’ high-risk prescribing such as the prescription of antipsychotics to people with dementia (more difficult because often started by one physician but reviewed by another, with greater fear of the consequences of stopping by both physician and carer, and more complicated stopping regimens). Is there anything else you would like to add?

Dr. Guthrie: Adverse drug effects (ADEs) cause approximately one in twenty emergency admissions to hospital, and are likely to get more common as polypharmacy in frail older people increases. Minimizing drug harms is therefore important for all physicians to do. Thank you for your contribution to the community.


Safer Prescribing — A Trial of Education, Informatics, and Financial Incentives

Tobias Dreischulte, Ph.D., Peter Donnan, Ph.D., Aileen Grant, Ph.D., Adrian Hapca, Ph.D., Colin McCowan, Ph.D., and Bruce Guthrie, M.B., B.Chir., Ph.D.

N Engl J Med 2016; 374:1053-1064

March 17, 2016
DOI: 10.1056/NEJMsa1508955

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Prof. Bruce Guthrie (2016). Informatics and Financial Incentives Can Lead To Safer Drug Prescribing